Florida-Based Health Plan Suspended for “Serious Threat” to the Health and Safety of Medicare Beneficiaries

Wednesday, March 9, 2016
By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On March 1, 2016, the Centers for Medicare and Medicaid Services (CMS) suspended a Florida insurer, Ultimate Health Plans Inc.(UHP), for posing a “serious threat” to Medicare beneficiaries. The sanction comes as a result of deficiencies including problems with compliance and coverage determinations involving Medicare Parts C and D. The insurer will no longer be able to enroll Medicare beneficiaries into any contracts and must suspend all marketing activities aimed at Medicare patients.

A Negative Audit From CMS.

CMS reportedly conducted the audit of UHP’s Medicare operations from October 26 through November 9, 2015. It concluded that the plan did not follow CMS requirements regarding Parts C and D organization and coverage determinations, appeals and grievances. Additionally, CMS said that UHP had an ineffective compliance program. “CMS found that UHP’s failures in these areas were widespread and systemic. Violations resulted in enrollees experiencing delays or denials in receiving medical services and prescription drugs, and increased out-of-pocket costs to ensure the resolution of compliance issues,” CMS said in a statement.

What Went Wrong.

UHP claims that most of the problems found during the audit resulted from its limited resources and the fact that it didn’t have enough staff dedicated to compliance. The compliance officer was also UHP’s operations officer, which as a result limited the time that person could effectively devote to compliance efforts. According to UHP, the plan’s medical director was also employed by both UHP and another physician’s group and no senior level staff member was devoted to overseeing the organization’s decision-making processes.

Earlier this year, Cigna faced similar sanctions, read about it here.

CMS said it will not lift the sanctions until it is satisfied that the problem upon which they are based have been corrected and aren’t likely to happen again. To read the notice given by CMS, click here.

To read a previous blog I wrote on this issue, click here.

This is big business in a highly regulated area.  Unless a company really understands this and is willing to invest the money in personnel, training and systems to properly operate such an insurer, then similar occurrences are likely to happen.

A Symptom of the "Privatization" Illness?

This is one of the biggest problems I see with the rhetoric of many politicians about "privatizing" Medicare and Medicaid. For-profit business entities will scrimp and scrimp on spending for sufficient personnel and equipment necessary to really do the job correctly, in order to make a profit to return to shareholders or investors.  The company will not function correctly and will go out of business leaving Medicare beneficiaries without healthcare and leaving the taxpayers, as usual, to pick up the pieces.  This should never be allowed to happen.  "Privatization" is just a scheme of smoke and mirrors to place taxpayer dollars into the pockets of rich investors.

Contact Attorneys Experienced in Defending Against Action to Exclude an Individual or Business from the Medicare Program.

The attorneys of The Health Law Firm have experience in dealing with RAC audits, ZPIC audits, pharmacy audits, DOH investigations, DEA investigations, the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS), and defending against action to exclude an individual or business entity from the Medicare Program, in administrative hearings on this type of action, in submitting applications requesting reinstatement to the Medicare Program after exclusion, and removal from the List of Excluded Individuals and Entities (LEIE).

To contact The Health Law Firm please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.


Kennedy, John. “Fla. Insurer Suspended Over 'Serious Threat' To Patients.” Law360. (March 1, 2016). Web.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law.  He is the President and Managing Partner of The Health Law Firm, which has a national practice.  Its main office is in the Orlando, Florida, area.  www.TheHealthLawFirm.com  The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone:  (407) 331-6620.

KeyWords: Medicare, Medicare fraud, Medicare abuse, Centers for Medicare and Medicaid Services, CMS, audits, CMS audits, Ultimate Health Plan Inc., prescribing practices, Medicare Part D and C, Medicare beneficiaries , RAC audit, ZPIC audit, administrative hearing, applying to Medicare, doctor’s license, suspended license, revoked license, compliance, CMS requirements, enroll in Medicare, Medicare overpayments, defense attorney, defense lawyer, health law, health law firm, The Health Law Firm

"The Health Law Firm" is a registered fictitious business name of George F. Indest III, P.A. - The Health Law Firm, a Florida professional service corporation, since 1999.
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